Visit Question Prioritizer
Patient: [Patient name]
Visit date: [Visit date]
Visit type: Upcoming doctor or clinic visit
Main goal: Leave with clear written next steps
Main concern I need addressed:
Write the core problem in one or two sentences. Example: symptoms are continuing, medication access is interrupted, a referral is delayed, testing was declined, or the plan is unclear.
Top question 1:
What is the most important question that must be answered before I leave or end the call?
Top question 2:
What is the second question that would prevent confusion, delay, or another unanswered follow-up?
Top question 3:
What is the third question that needs a direct answer, referral, test, record review, or written care-plan clarification?
The detail I do not want missed:
Name the specific detail that often gets minimized or skipped: pain severity, nausea/intake, standing intolerance, neurological symptoms, medication access, functional loss, safety concern, or prior failed follow-up.
Pattern or timing summary:
Summarize timing, triggers, flares, recovery time, or what makes symptoms worse. Keep it short enough to read during a visit.
Functional impact:
Explain how this affects sleep, eating, hydration, standing, walking, work, school, caregiving, driving, safety, or daily function.
Care barrier or prior follow-up history:
List prior messages, calls, records requests, pharmacy issues, insurance barriers, referrals, testing requests, or unanswered follow-up by date or short summary. Do not paste full records.
Requested outcome:
State what you are asking for: written plan, medication access clarification, referral, testing, records review, follow-up timeframe, return precautions, or who owns the next step.
Closing request to use during the visit:
Before we finish, can you please confirm the plan in writing, what symptoms should trigger urgent care, who owns the next step, and when I should follow up if this is not resolved?
Privacy reminder:
This was prepared in a browser-only organizer. Pain Care Rights does not upload, save, submit, email, or store this information.